Endoscopic Studies
Overview
Indications For Endoscopy
Endoscopy is a general term referring to the inspection of the internal body organs and cavities by using an instrument called an endoscope. Endoscopic procedures are named for the organ or body area to be visualized and/or treated. Table 4-1 provides an overview of body areas viewed by endoscopy.
TABLE 4-1
Types of Endoscopies and Areas of Visualization
| Type | Area of Visualization |
| Arthroscopy | Joints |
| Bronchoscopy | Larynx, trachea, bronchi, and alveoli |
| Colonoscopy | Rectum and colon |
| Colposcopy | Vagina and cervix |
| Cystoscopy | Urethra, bladder, ureters, and prostate |
| Enteroscopy | Upper colon and small intestines |
| Endoscopic retrograde cholangiopancreatography (ERCP) | Pancreatic and biliary ducts |
| Esophagogastroduodenoscopy (EGD) | Esophagus, stomach, duodenum |
| Fetoscopy | Fetus |
| Gastroscopy (part of EGD) | Stomach |
| Hysteroscopy | Uterus |
| Laparoscopy | Abdominal cavity |
| Mediastinoscopy | Mediastinal lymph nodes |
| Sigmoidoscopy | Anus, rectum, sigmoid colon |
| Sinus endoscopy | Sinus cavities |
| Thoracoscopy | Pleura and lung |
| Transesophageal echocardiography (TEE) | Heart |
| Urologic endoscopy (endourology) | Bladder and urethra |
In addition to direct observation, endoscopy permits biopsy of suspicious tissue, removal of polyps, injection of variceal blood vessels, and the performance of many surgical procedures as indicated in Box 4-1. Furthermore, areas of stricture within a lumen of a hollow viscus can be dilated and stented during endoscopy.
Instrumentation
Endoscopes are tubular instruments with a light source and a viewing lens for observation. The endoscope can be inserted through a body orifice (e.g., rectum) or through a small incision (e.g., arthroscopy). There are two basic types of endoscopes: rigid and flexible. Rigid metal scopes were the first type available and are still used in operative endoscopy (e.g., arthroscopy). Flexible fiberoptic scopes are most often used in pulmonary and gastrointestinal (GI) endoscopy. An example of a flexible fiberoptic endoscope used in esophagogastroduodenoscopy (EGD) is shown in Figure 4-1. These scopes allow the transmission of images over flexible, light-carrying bundles of glass wires. The scopes contain an accessory lumen(s) for the insertion of water or medication or the suctioning of debris. Also, instruments can be inserted through these lumens to do the following:
Most often endoscopic procedures are performed via a video chip in the tip of a camera that is placed over the viewing lens. The image is then transmitted in color to a nearby television monitor (Figure 4-2) where body cavities or organs are viewed. This permits others in the room to observe the procedure and more actively provide assistance. In many situations, endoscopy eliminates the need for open surgery.
Procedural Care for the Endoscopy Patient
Pulmonary and Gastrointestinal Endoscopy
Endoscopic procedures are generally considered invasive. Client preparation and care are similar to those for most minor surgical procedures. General principles are described in this section. Detailed descriptions are included in this chapter with each individual test.
Before
• Ensure that written and informed consent is obtained from the patient.
• Preparation varies with the type of endoscopy to be performed. For example, gastroscopy requires that the patient be kept on nothing by mouth (NPO) status for 8 to 12 hours before the procedure to prevent vomiting and aspiration.
• Dentures should be removed, and loose teeth should be noted and recorded.
• For colonoscopy the bowel must be cleansed and free of fecal material to allow adequate visualization of the mucosa.
• GI endoscopy should precede barium contrast studies. Barium can coat the GI mucosa and preclude adequate visualization of the mucosa.
• Baseline laboratory tests (e.g., measurement of hemoglobin, hematocrit, electrolyte levels) should be performed, especially if a surgical procedure or biopsy is possible.
• A history concerning bleeding tendencies and allergies should be obtained before the procedure.
• Because GI endoscopy is considered clean (not sterile), intravenous (IV) antibiotics are recommended for patients who have cardiac valvular disease (to prevent endocarditis) or patients who have prosthetic joints (to prevent seeding of the joint).
During
• Endoscopic procedures are preferably performed in a specially equipped endoscopy room or in the operating room. However, in cases of emergency, endoscopy can be performed at the bedside.
• Because sedation is provided, resuscitative equipment should be available.
• Air or CO2 is instilled into the bowel during GI endoscopy to maintain patency of the bowel lumen and to allow better visualization of the mucosa. If cautery is to be used, the air is exchanged for carbon dioxide to prevent ignition of oxygen or methane inside the bowel.
• Because air or CO2 insufflation is used, the patient may experience gas pains during the procedure and after the procedure.
After
• Specific postprocedure interventions are determined by the type of endoscopic examination performed. All GI procedures have the potential complication of perforation and bleeding. See the discussion of potential complications.
• These procedures use sedation. Safety precautions (such as someone staying with the patient) should be observed until the effects of the sedatives have worn off.
• A family member or friend should drive the patient home after the test.
• After lower GI tract endoscopy, the patient may complain of rectal discomfort. A warm tub bath may be soothing.
• Usually the patient is kept on NPO status for 2 hours after pulmonary endoscopy or upper GI tract endoscopy. Be certain that the swallowing mechanism and cough reflex have returned to normal before allowing fluids or food.
Operative Endoscopy and Endourology
Before
These procedures usually require general anesthesia. Furthermore, complications of operative endoscopy may require open surgical treatment. Therefore the patient must be prepared for general anesthesia and the possibility of open surgery. Routine preoperative care and teaching must be performed.
• The area to be examined should be shaved to remove hair if preferred by the surgeon.
Because genitourinary (GU) endoscopy is considered clean (not sterile), IV antibiotics are recommended for patients who have cardiac valvular disease (to prevent endocarditis) or patients who have prosthetic joints (to prevent seeding of the joint).
During
• During laparoscopy, CO2 is instilled into the peritoneal cavity. This may cause significant gas pains and referred shoulder pain postoperatively if not all the CO2 is allowed to escape.
• During cystoscopy, water is used to distend the bladder to allow visualization of the bladder mucosa. Accurate measurement of intake and output is difficult.
• The appropriate surgical procedure is performed as indicated in each test.
Potential Complications of Endoscopy
Specific complications depend on the type of endoscopic procedure performed. The following guidelines apply to most types of endoscopies.
Perforation of Organ or Cavity
Examine the abdomen for evidence of organ perforation. Assess for abdominal distention, tenderness, and pain.
Persistent Bleeding from a Biopsy Site
Assess the vital signs. Watch for a decrease in blood pressure and an increase in pulse rate. Inspect body secretions (such as stool, urine, sputum) for blood.
Respiratory Depression as a Result of Oversedation
Carefully assess the patient for respiratory depression. Naloxone (Narcan) may be used to reverse opiates, such as fentanyl or morphine. Flumazenil (Romazicon) may be used to reverse the effects of benzodiazepines, such as diazepam (Valium) and midazolam (Versed).
Infections and Transient Bacteremia
This is a special concern with cystoscopy. Patients need to be encouraged to drink a lot of fluids to maintain a constant flow of urine to prevent stasis and accumulation of bacteria in the bladder. Observe also for signs and symptoms of sepsis, which include elevated temperature, flushing, chills, hypotension, and tachycardia.
Reporting of Results
Most results are directly observed by the physician performing the procedure. Tissues for biopsy or culture need to be sent to the laboratory for evaluation. Results are discussed with the patient as soon as the effect of any sedation has worn off. However, because the sedation has an amnesic effect, the patient may not recall the results of the test. If possible a written reminder of the physician's findings and instructions should be provided to the patient.
Arthroscopy
Indications
Arthroscopy is an endoscopic procedure that allows examination of a joint interior with a specially designed endoscope.
Test Explanation
Arthroscopy is a highly accurate test because it allows direct visualization of an anatomic site (Figure 4-3). Although this technique can visualize many joints of the body, it is most often used to evaluate the knee for meniscus cartilage or ligament injury. It is also used in the differential diagnosis of acute and chronic disorders of the knee (e.g., arthritic inflammation versus injury).
Figure 4-3 Arthroscopy. The arthroscope is placed within the joint space of the knee. Video arthroscopy requires the availability of a water source to distend the joint space, a light source to see the contents of the joint, and a TV monitor to project the image. Other trocars are used for access of the joint space for other operative instruments.
Physicians can now perform corrective surgery on the knee through the endoscope. Meniscus removal, spur removal, ligamentous repair, and biopsy are but a few of the procedures that are done through the arthroscope. Arthroscopy provides a safe, convenient alternative to open surgery (arthrotomy) because surgery is done through small trocars that are placed into the joint. Surgical maneuvers are carried out under direct vision of the camera that is attached to the arthroscope. Because a large incision is avoided, recovery is faster and more comfortable.
Arthroscopy is also used to monitor the progression of disease and the effectiveness of therapy. Visual findings may be recorded by attaching a video camera to the arthroscope. Joints that can be evaluated by the arthroscope include the tarsal, ankle, knee, hip, carpal, wrist, shoulder, and temporomandibular joints. Synovial fluid can be obtained for fluid analysis (see Arthrocentesis, p. 640).
This procedure is performed in the operating room by an orthopedic surgeon in approximately 30 minutes to 2 hours. Patients receiving local anesthesia have transient discomfort from the injection of the local anesthetic and the pressure of the tourniquet. A thumping sensation may be felt as the arthroscope is inserted into the joint. The joint may be painful and slightly swollen for several days or weeks, depending on the extent of surgery performed.
Contraindications
• Patients with ankylosis, because it is almost impossible to maneuver the instrument into a joint stiffened by adhesions
• Patients with local skin or wound infections, because of the risk of sepsis
• Patients who have recently had an arthrogram, because they will have some residual inflammation subsequent to the injection of the contrast dye
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Ensure that the physician has obtained written consent for this procedure.
• Follow the routine preoperative procedure of the institution.
Keep the patient on nothing by mouth (NPO) status after midnight on the day of the test because general anesthesia is usually required.
Tell the patient to use crutches after arthroscopy until he or she can walk without limping. Instruct the patient regarding the appropriate crutch gait.
• Shave the hair in the area 6 inches above and below the joint before the test (as ordered).
During
• Place the patient on his or her back on an operating room table.
• Note the following procedural steps:
1. General anesthesia is usually used to diminish pain and to allow for complete relaxation of the muscles around the knee.
2. The leg is carefully scrubbed, elevated, and wrapped with an elastic bandage from the toes to the lower thigh to drain as much blood from the leg as possible.
3. A tourniquet is placed on the patient's leg. If the tourniquet is not used, a fluid solution (usually saline) is instilled into the patient's knee immediately before insertion of the arthroscope to distend the knee and to help reduce bleeding.
4. The foot of the table is lowered so that the patient's knee can be bent between a 45- and a 90-degree angle.
5. A small incision is made in the skin around the knee.
6. The arthroscope (a lighted instrument) is inserted into the joint space to visualize the inside of the knee joint.
7. Although the entire joint can be viewed from one puncture site, additional punctures for better visualization and surgical maneuvers are often necessary.
8. After the area is examined, biopsy or appropriate surgery can be performed.
9. Before removal of the arthroscope, the joint is irrigated. Steroids are sometimes injected to decrease inflammation. Pressure is then applied to the knee to remove the irrigating solution.
10. After a few stitches are placed into the skin, a pressure dressing is applied over the incision site.
After
• Assess the patient's neurologic and circulatory status.
• Assess vital signs and observe the patient for signs of bleeding or infection.
Instruct the patient to elevate the knee when sitting and to avoid overbending the knee so that swelling is minimized.
Inform the patient that he or she can usually walk with the assistance of crutches; however, this depends on the extent of the procedure and the physician's protocol. A referral may be made for physical therapy.
Tell the patient to minimize use of the joint for several days.
• Examine the incision site for bleeding.
• Apply ice to reduce pain and swelling.
Inform the patient that the sutures will be removed in approximately 7 to 10 days.
Home Care Responsibilities
• Teach the patient to walk on crutches.
• Educate the patient to observe for signs of bleeding into the joint (significant swelling, increasing pain, or joint weakness).
• Teach the patient to observe for signs of infection of the joint (fever, swelling, drainage, redness about the joint, and increasing pain).
• Educate the patient to observe for signs of phlebitis. This is not uncommon in a person immobilized by joint pain. The involved leg may become swollen, painful, and edematous.
• Instruct the patient not to drive until approved by the physician.
• Ice should be applied at home to minimize the normal swelling that may occur around the involved joint.
Test Results and Clinical Significance
Torn cartilage: Either meniscus (in the knee) is fractured. It may further injure the underlying joint surface.
Torn ligament: Ligaments support the joint. Injury to this structure weakens joint stability.
Fracture, inflammation, and malformation can be seen with knee arthroscopy.
Chondromalacia: Disease or structural damage to the cartilaginous joint surfaces can cause joint pain and dysfunction.
Osteochondritis dissecans: Injury to the joint surfaces can occur as a result of joint fragments in the joint space.
Cyst (e.g., Baker): This is a synovial cyst behind the knee as a result of synovial fluid herniating into the soft tissue surrounding the knee.
Synovitis: This is an inflammation of the lining of the joint.
Destruction of the articular surfaces causes inflammation in the joint.
Trapped synovium: Synovial tissue can become trapped between two bones of the joint, causing pain and inflammation.
Related Tests
Arthrocentesis (p. 640). This procedure is performed by inserting a needle into the joint space to obtain synovial fluid for analysis.
Arthrography. This x-ray test of the joint space provides information about anatomic and disease abnormalities affecting the joint.
Magnetic Resonance Imaging (MRI) of the Knee (p. 1106). This scanning technique provides valuable information by placing the patient in a magnetic field.
Bronchoscopy
Indications
Bronchoscopy permits endoscopic visualization of the larynx, trachea, and bronchi by either a flexible fiberoptic bronchoscope or a rigid bronchoscope. Reasons for these procedures are described below.
Test Explanation
There are many diagnostic and therapeutic uses for bronchoscopy. Diagnostic uses of bronchoscopy include the following:
1. Direct visualization of the tracheobronchial tree for abnormalities (e.g., tumors, inflammation, strictures)
2. Biopsy of tissue from observed lesions
3. Aspiration of “deep” sputum for culture and sensitivity and for cytologic determinations
4. Direct visualization of the larynx for identification of vocal cord paralysis, if present. With pronunciation of “eeee” the cords should move toward the midline.
Therapeutic uses of bronchoscopy include the following:
1. Aspiration of retained secretions in patients with airway obstruction or postoperative atelectasis
2. Control of bleeding within the bronchus
3. Removal of foreign bodies that have been aspirated
4. Brachytherapy, which is endobronchial radiation therapy using an iridium wire placed via the bronchoscope
5. Palliative laser obliteration of bronchial neoplastic obstruction
The rigid bronchoscope is a wide-bore metal tube that permits visualization of only the larger airways. It is used mainly for the removal of large foreign bodies. Its use has radically diminished since the advent of the newer flexible fiberoptic bronchoscope.
Because of its smaller size and its flexibility, the flexible fiberoptic bronchoscope has increased the diagnostic reach to the smaller bronchi. It also has accessory lumens through which cable-activated instruments can be used for removing biopsy specimens of pathologic lesions (Figure 4-4). In addition, the collection of bronchial washings (obtained by flushing the airways with saline solution), respiratory hygiene, and the instillation of anesthetic agents can be carried out through these extra lumens. Double-sheathed, plugged protected brushes also can be passed through this accessory lumen. Specimens for cytologic and bacteriologic study can be obtained with these brushes. This allows more accurate determination of pulmonary infectious agents. Needles or biopsy forceps can be placed through the scope to obtain biopsy specimens from tissue immediately adjacent to the bronchi. Laser therapy can now be performed through the bronchoscope to burn out endotracheal lesions.
Figure 4-4 Flexible fiberoptic bronchoscope. The four channels consist of two that provide a light source, one vision channel, and one open channel that accommodates instruments or allows administration of an anesthetic or oxygen.
This procedure is performed by a physician, usually a pulmonary specialist or a surgeon, in approximately 30 to 45 minutes. No discomfort is usually felt. This test is performed at the bedside or in an appropriately equipped endoscopy room.
Laryngoscopy is often performed through a short bronchoscope to allow inspection of the larynx and perilaryngeal structures. This is most commonly performed by an ENT surgeon. Cancers, polyps, inflammation, and infections of those structures can be identified. The vocal cord motion can be evaluated also. Anesthesiologists use laryngoscopy to visualize the vocal cord structures on patients who are difficult to intubate for general anesthesia. In this instance, the laryngoscope is shaped very much like a rigid scope routinely used to see the vocal cords under direct visualization using retraction of the anterior neck during intubation. This endoscopic laryngoscope, however, is attached to a camera that projects the image of the vocal cords onto a monitor.
Contraindications
• Patients with hypercapnia and severe shortness of breath who cannot tolerate interruption of high-flow oxygen (Bronchoscopy, however, can be performed through a special oxygen mask or an endotracheal tube so that the patient can receive oxygen if required.)
• Patients with severe tracheal stenosis, which may make it difficult to pass the scope
Age-Related ConcernsProcedure and Patient Care
Before
Explain the procedure to the patient. Allay any fears and allow the patient to verbalize any concerns.
• Obtain informed consent for this procedure.
• Keep the patient on nothing by mouth (NPO) status for 4 to 8 hours before the test to reduce the risk of aspiration.
Instruct the patient to perform thorough mouth care to minimize the risk of introducing bacteria into the lungs during the procedure. Assist if needed.
• Remove and safely store the patient's dentures, glasses, or contact lenses before administering the preprocedural medications.
• Administer the preprocedural medications as ordered. Atropine may be used to prevent vagal-induced bradycardia and to minimize secretions. Fentanyl or versed may be used to sedate the patient and relieve anxiety.
Reassure the patient that he or she will be able to breathe during this procedure.
Instruct the patient not to swallow the local anesthetic sprayed into the throat.
During
• Note the following procedural steps for fiberoptic bronchoscopy:
1. The patient's nasopharynx and oropharynx are anesthetized topically with lidocaine spray before the insertion of the bronchoscope. A bite block may be used.
2. The patient is placed in the sitting or supine position, and the scope is inserted through the nose or mouth and into the pharynx (Figure 4-5).
3. After the scope passes into the larynx and through the glottis, more lidocaine is sprayed into the trachea to prevent the cough reflex.
4. The scope is passed farther, well into the trachea, bronchi, and the first- and second-generation bronchioles, for systematic examination of the bronchial tree.
5. Biopsy specimens and washings are taken if a pathologic condition is suspected.
6. If bronchoscopy is performed for pulmonary hygiene (removal of mucus), each bronchus is aspirated until clear.
7. Monitor the patient's oxygen saturation to be sure that the patient is well oxygenated. These patients often have pulmonary diseases that already compromise their oxygenation. When a scope is placed, breathing may be further impaired.
After
Instruct the patient not to eat or drink anything until the tracheobronchial anesthesia has worn off and the gag reflex has returned.
• Observe the patient's sputum for hemorrhage if biopsy specimens were removed. A small amount of blood streaking may be expected and is normal for several hours. Large amounts of bleeding can cause a chemical pneumonitis.
• Observe the patient closely for evidence of impaired respiration or laryngospasm. The vocal cords may go into spasms after intubation. Emergency resuscitation equipment should be readily available.
Inform the patient that postbronchoscopy fever often develops within the first 24 hours. A low-grade temperature is normal.
• If a tumor is suspected, collect a postbronchoscopy sputum sample for a cytologic determination.
Inform the patient that warm saline gargles and lozenges may be helpful if a sore throat develops.
• Note that a chest x-ray film may be ordered to identify a pneumothorax if a deep biopsy was obtained.
Home Care Responsibilities
• Suggest that the patient gargle with saline or soothing mouthwash to minimize a sore throat.
• Fever is not uncommon after bronchoscopy. High persistent fever should be reported immediately.
• Bronchospasm or laryngospasm should be reported immediately to emergency personnel.
• Inform the patient that biopsy or culture reports will be available in 2 to 7 days.
Test Results and Clinical Significance
Inflammation: Bronchitis is readily obvious with this method. Cultures can be obtained to identify infections.
Strictures: Strictures can be identified and sometimes dilated with this technique.
Cancer: Neoplasm of the larynx, bronchus, or lung can be identified, and a biopsy can be performed. The extent of the tumor and its resectability can sometimes be determined. The amount of lung that is required to be removed can be estimated at bronchoscopy. Laser energy can be delivered to diminish the intraluminal size of the tumor. Iridium radiation strips can be positioned accurately at bronchoscopy.
Hemorrhage: Hemorrhage can be identified and sometimes controlled by this technique. The source of the hemorrhage can be determined.
Foreign body: Often foreign bodies can be removed by fiberoptic flexible bronchoscopy. Large-bore rigid bronchoscopy may be required.
Abscess: Pockets of infection can be diagnosed and drained by bronchoscopy. Valuable cultures can be obtained.
Infection: Infections can be identified and cultures can be obtained to provide information for treatment. Difficult-to-grow organisms can be better cultured by this technique. This is especially helpful for tuberculosis, fungal infections, and Pneumocystis jiroveci.
Colonoscopy
Indications
This test allows for direct visualization of the rectum, colon, and small bowel. It is used to diagnose suspected pathologic conditions of these organs. It is recommended for patients who have had a change in bowel habits or obvious or occult blood in the stool or who have abdominal pain. It is also used as a surveillance tool for patients who have had colorectal cancer, inflammatory bowel disease, or polyposis.
Test Explanation
With fiberoptic colonoscopy the entire colon from anus to cecum (and often a portion of terminal ileum) can be examined in most patients. (Table 4-2 lists types of gastrointestinal [GI] endoscopies.) As with sigmoidoscopy (p. 623), benign and malignant neoplasms, polyps, mucosal inflammation, ulceration, and sites of active hemorrhage can be visualized. Diseases such as cancer, polyps, ulcers, and arteriovenous (AV) malformations also can be visualized. Biopsy specimens of cancers, polyps, and inflammatory bowel diseases can be taken through the colonoscope with cable-activated instruments. Sites of active bleeding can be coagulated with the use of laser, electrocoagulation, and injection of sclerosing agents.
TABLE 4-2
| Endoscopy | Portion of Bowel Examined |
| Anoscopy | Anus and distal rectum |
| Proctoscopy | Rectum |
| Sigmoidoscopy | |
| Rigid | Anus, rectum, and sigmoid colon to 25 cm |
| Flexible | Anus, rectum, and sigmoid colon to 60 cm |
| Colonoscopy | Anus, rectum, and entire colon |
This test is recommended for patients who have Hemoccult-positive stools, abnormal sigmoidoscopy, lower GI tract bleeding, or a change in bowel habits. This test is also recommended for patients who are at high risk for colon cancer. They include patients with a strong personal or family history of colon cancer, polyps, or ulcerative colitis. Colonoscopy is also used for colorectal screening in asymptomatic patients without increased risks for cancer. This screening for colorectal cancer has been well defined by several professional organizations such as The U.S. Preventive Services Task Force on Screening for Colorectal Cancer and the American Cancer Society. The recommendations vary slightly, but are summarized in Table 4-3. Virtual colonoscopy (see p. 1020) is now an option.
The test is performed by a physician trained in GI endoscopy in approximately 30 to 60 minutes. It is usually performed in an endoscopy suite or the operating room. Because the patient is heavily sedated, he or she experiences very little discomfort and may not have recall of the procedure.
See p. 1020 for a discussion of a virtual colonoscopy.
Contraindications
• Patients who are uncooperative: As in all studies that require technical finesse, patient cooperation is essential to successful completion of the test.
• Patients whose medical conditions are not stable: This test requires sedation, which may induce hypotension in medically unstable patients.
• Patients who are bleeding profusely from the rectum: The viewing lens will become covered with blood clots, preventing visualization of the lower intestinal tract.
• Patients with a suspected perforation of the colon: The air insufflated during colonoscopy may worsen the fecal peritoneal soilage.
• Patients with toxic megacolon: The condition may worsen with the test preparation.
• Patients with a recent colon anastomosis (within the past 14 to 21 days): The anastomosis may break down with significant insufflation of carbon dioxide.
Interfering Factors
• Poor bowel preparation may result in the stool immediately obstructing the lens and precluding adequate visualization of the colon.
• Active bleeding may obstruct the lens system and preclude adequate visualization of the colon.
Clinical Priorities
• Patients need to drink large amounts of fluids to preclude dehydration from the test preparation.
• It is recommended that the patient drink the entire gallon of the glycol preparation within 4 hours.
• Nausea and vomiting should indicate immediate cessation of the preparation procedure.
• Patients with valvular heart disease should receive prophylactic antibiotics before the test.
Procedure and Patient Care
Before
Explain the procedure to the patient.
Fully inform the patient about the risks of the procedure and obtain an informed consent.
Instruct the patient in the appropriate bowel preparation. One type is the 2-day bowel preparation, which uses clear liquids for 2 days, along with a strong cathartic such as magnesium citrate and bisacodyl (Dulcolax). On the day of examination, an enema is given. A 1-day preparation involving a clear liquid diet and using a glycol bowel preparation (Colyte or GoLYTELY) is more widely used. Flavor packets from the manufacturer may improve the flavor. After the patient ingests the glycol solution, enemas are not usually needed.
• The gallon should be consumed within 4 hours if possible.
• Lemonade powder may be added to the glycol cathartic to improve its flavor.
• Avoid an oral bowel preparation in patients with upper GI tract obstruction, suspected acute diverticulitis, or recent bowel resection surgery.
Assure patients that they will be appropriately draped to avoid unnecessary embarrassment.
• Administer appropriate preendoscopy sedation, usually Fentanyl and midazolam (Versed). Atropine is often ordered to minimize patient secretions.
During
• Note the following procedural steps:
1. Intravenous (IV) access is obtained for sedation and analgesia.
2. After a rectal examination indicates adequate bowel preparation, the patient is sedated.
3. The patient is placed in the lateral decubitus position, and the colonoscope is placed into the rectum.
4. Under direct visualization, the colonoscope is directed to the cecum. Often a significant amount of manipulation is required to obtain this position.
5. As in all endoscopy, air is insufflated to distend the bowel for better visualization.
6. Complete examination of the large bowel is carried out.
7. Polypectomy, biopsy, and other endoscopic surgery is performed after appropriate visualization.
8. When the laser or coagulator is used, the air is removed and carbon dioxide is used as an insufflating agent to avoid explosion.
After
Explain to the patient that air has been insufflated into the bowel. The patient may experience flatulence or gas pains.
• Examine the abdomen for evidence of colon perforation (abdominal distention and tenderness).
• Monitor the patient's vital signs for a decrease in blood pressure and an increase in pulse rate as an indication of hemorrhage.
• Inspect the stools for gross blood.
• Notify the physician if the patient develops increased pain or significant GI bleeding.
• Allow the patient to eat when fully alert if no evidence of bowel perforation exists.
Encourage the patient to drink large amounts of fluids when intake is allowed. This will make up for the dehydration associated with the bowel preparation.
Test Results and Clinical Significance
Colon cancer: This is seen as a red, friable, fleshy tumor concentrically involving the mucosa of the bowel.
Colon polyp: This is a tumor that protrudes from only one part of the mucosa of the bowel. Some cancers and most polyps can be removed with the colonoscope. A biopsy specimen can be obtained from neoplasms.
Home Care Responsibilities
• Observe for increasing abdominal pain, which may indicate bowel perforation.
• Inform the patient that frequent, bloody bowel movements may indicate poor hemostasis if biopsy or polypectomy was performed.
• Observe for abdominal bloating and inability to pass flatus, which may indicate colon obstruction if a neoplasm was identified.
• Assess for weakness and dizziness, which may indicate orthostasis and hypovolemia because of dehydration.
• Evaluate for fever and chills, which may indicate a bowel perforation.
Inflammatory bowel disease (e.g., ulcerative or Crohn colitis): The mucosa of the bowel is red, friable, and thickened. Patients with ulcerative colitis are at great risk for the development of cancer over time. These patients should frequently undergo colonoscopy to identify any cancer or precancerous conditions.
AV malformations: These are small red dots on the mucosa of the bowel. They are a common form of bleeding in the adult, especially those with aortic sclerosis and valvular disease. These lesions can be fulgurated by electrocautery through the colonoscope.
Hemorrhoids: These are excess fleshy tissue immediately inside the anus.
Diverticulosis: This is the presence of diverticula, which are outpouchings in the wall of the colon. Recognition of these abnormalities is important but usually does not require surgical therapy.
Ischemic or postinflammatory stricture: This is a fibrotic narrowing of the bowel lumen. Stricture may follow any injury to the bowel. It is a result of fibrosis and scarring that follows an acute insult to the bowel.
Related Tests
Barium Enema (p. 994). This is another form of visualization of the bowel. It is not as accurate as colonoscopy.
Virtual Colonoscopy (p. 1020). This is a noninterventional method of examining the entire colon by using computerized tomography. Positron Emission Tomography (PET) scan (p. 821) may be added to the CT scan and will add accuracy to this form of colon examination.
Septin 9 DNA Methylation Assay (p. 460). This blood test is used to screen asymptomatic patients for colorectal cancer.
Colposcopy
Indications
Colposcopy is used to identify malignant and premalignant lesions of the vagina and cervix. It is helpful in the more thorough evaluation of abnormal Papanicolaou (Pap) tests.
Test Explanation
Colposcopy provides an in situ macroscopic examination of the vagina and the cervix with a colposcope, which is a macroscope with a light source and a magnifying lens (Figure 4-6). With this procedure, tiny areas of dysplasia, carcinoma in situ, and invasive cancer that would be missed by the naked eye can be visualized, and biopsy specimens can be obtained. The study is performed on patients with abnormal vaginal epithelial patterns, cervical lesions, or suspicious Pap test results and on those women who were exposed to diethylstilbestrol in utero. It may be a sufficient substitute for cone biopsy (removal and examination of a cone of tissue from the cervix) in evaluating the cause of abnormal cervical cytologic findings (Table 4-4).
TABLE 4-4
| Test | Advantage | Disadvantage(s) |
| Colposcopy | Evaluates the vagina and cervix | Cannot evaluate the endocervix High false-positive rate |
| Hysteroscopy | Evaluates the endometrium | Cannot evaluate the cervix and endocervix |
| Cone biopsy of the cervix | Evaluates the cervix and endocervix | Cannot evaluate the endometrium |
| Pap test | Evaluates the cervix, endocervix, and endometrium | Misses important pathologic conditions of those tissues and may overread inflammation Cannot localize the lesion |
Figure 4-6 Colposcopy. A colposcope is used to evaluate patients with an abnormal Pap test and a grossly normal cervix.
It is important to realize that colposcopy is useful only in identifying a suspicious lesion. Definitive diagnosis requires biopsy of the tissue. One of the major advantages of this procedure is that of directing the biopsy to the area most likely to be truly representative of the lesion. A biopsy performed without colposcopy may not necessarily be representative of the lesion's true pathologic condition, resulting in a significant risk of missing a serious lesion.
The patient will need to have diagnostic conization in the following instances:
1. Colposcopy and endocervical curettage do not explain the problem or match the cytologic findings of the Pap test within one grade.
2. The entire transformation zone (between squamous and columnar epithelium) is not seen. This area is also called the endocervix, in which many cancers can initiate.
3. The lesion extends up the cervical canal beyond the vision of the colposcope.
The need for up to 90% of cone biopsies is eliminated with examination by an experienced colposcopist. Endocervical curettage may accompany colposcopy to detect unseen lesions in the endocervical canal.
Colposcopy is performed by a physician, nurse practitioner, or physician's assistant in approximately 5 to 10 minutes. Some women complain of pressure pains from the vaginal speculum, and momentary discomfort may be felt if biopsy specimens are obtained. If the discomfort exceeds that which mild sedation treats, a paracervical block can be performed.
Procedure and Patient Care
During
• Note the following procedural steps:
1. The patient is placed in the lithotomy position, and a vaginal speculum is used to expose the vagina and cervix. An endocervical curettage is performed to minimize any dropping of endocervical cells onto the external surface of the cervix.
2. After the cervix is sampled for cytologic findings, it is cleansed with a 3% acetic acid solution to remove excess mucus and cellular debris. The acetic acid also accentuates the difference between normal and abnormal epithelial tissues.
3. The colposcope is focused on the cervix, which is then carefully examined. Photographs and rough sketches of the cervix may be created.
4. Usually the entire lesion can be outlined, and the most atypical areas can be selected for biopsy specimen removal.
5. A biopsy can be performed at this time on any abnormality.
After
• The cervix is cleaned with normal saline solution, and hemostasis is ensured.
Inform the patient that she may have vaginal bleeding if biopsy specimens were taken. Suggest that she wear a sanitary pad.
Instruct the patient to abstain from intercourse and not to insert anything (except a tampon) into the vagina until healing of the biopsy is confirmed.
Inform the patient when and how to obtain the results of this study.
Related Tests
Cervical Biopsy (p. 720). A biopsy of the cervix is performed to more accurately identify and treat premalignant and superficial malignant lesions of the cervix.
Papanicolaou (Pap) Test (p. 743). This is a test of the cells that have been shed by the cervix and uterus. Early detection of cancer of the uterus and cervix can be accomplished by routine use of this test.
Conization/Cytology (p. 720). A concentric piece of cervix and endocervix is obtained for microscopic evaluation.
Cystoscopy (Endourology)
Indications
This endoscopic test is used to evaluate patients with suspected pathologic conditions involving the urethra, bladder, and lower ureters. It is also used to perform a biopsy on and to treat pathologic conditions related to those structures. This procedure is commonly performed for patients with the following problems:
Test Explanation
Cystoscopy provides direct visualization of the urethra and bladder through the transurethral insertion of a cystoscope into the bladder (Figure 4-7). Cystoscopy is used diagnostically to allow the following:
1. Direct inspection and biopsy of the prostate, bladder, and urethra
2. Collection of a separate urine specimen directly from each ureter by the placement of ureteral catheters
3. Measurement of bladder capacity and determination of ureteral reflux
4. Identification of bladder and ureteral calculi
5. Placement of ureteral catheters (Figure 4-8) for retrograde pyelography (p. 1056)
Cystoscopy is used therapeutically to provide the following:
1. Resection of small, superficial bladder tumors (transurethral resection of the bladder)
2. Removal of foreign bodies and stones
3. Dilation of the urethra and ureters
4. Placement of stents to drain urine from the renal pelvis
5. Coagulation of bleeding areas
6. Implantation of radium seeds into a tumor
7. Resection of hypertrophied or malignant prostate gland overgrowth (transurethral resection of the prostate [TURP])
8. Placement of ureteral stents for identification of ureters during pelvic surgery
The cystoscope consists primarily of an obturator and a telescope. The obturator is used to insert the cystoscope atraumatically. After the cystoscope is within the bladder, the obturator is removed and the telescope is passed through the cystoscope. The lens and lighting system of the telescope permit adequate visualization of the lower genitourinary (GU) tract. Transendoscopic instruments, such as forceps, scissors, needles, and electrodes, are used when needed.
Endourology is an endoscopic procedure that visualizes the bladder and urethra. It is more comprehensive than cystoscopy because it includes a detailed visualization of the urethra. This test is important in the evaluation of hematuria, chronic infection, suspected stones, and radiographic filling defects. On inspection the urethra may show inflammation or structural causes of obstruction (e.g., stricture, neoplasia, prostatic hypertrophy). If the obstruction is functional rather than structural (e.g., detrusor–bladder neck dyssynergia), no site of obstruction will be demonstrated by endoscopy.
Although usually performed in the operating room using general anesthesia, diagnostic cystoscopy can be done in the urologist's office in about 10 minutes. A flexible scope is used for this. The urethra is anesthetized with an anesthetic gel. The only discomfort felt is when the scope passes through the sphincter. When a rigid scope is to be used for diagnostic or therapeutic cystoscopy, general or spinal anesthesia is used.
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Ensure that an informed consent is obtained.
If enemas are ordered to clear the bowel, assist the patient as needed and record the results.
Encourage the patient to drink fluids the night before the procedure to maintain a continuous flow of urine for collection and to prevent multiplication of bacteria that may be introduced during this technique.
• If the procedure will be done using local anesthesia, small volumes of liquids may be acceptable. Verify this with the doctor.
When local anesthesia will be used, inform the patient of the associated discomfort (much more than with urethral catheterization).
If the procedure will be performed with the patient under general anesthesia, follow routine precautions. Keep the patient on nothing by mouth (NPO) status after midnight on the day of the test. Intravenous fluids may be given.
• Administer the preprocedural medications as ordered 1 hour before the study. Sedatives decrease the spasm of the bladder sphincter, decreasing the patient's discomfort.
During
• Note the following procedural steps:
1. Cystoscopy is performed in the operating room or in the urologist's office.
2. The patient is placed in the lithotomy position with his or her feet in stirrups.
3. The external genitalia are cleansed with an antiseptic solution such as povidone-iodine (Betadine).
4. A local anesthetic gel is instilled into the urethra if the patient is not under general anesthesia.
5. The cystoscope is inserted, and the bladder is distended with saline.
6. The desired diagnostic or therapeutic studies are performed.
Instruct the patient to lie very still during the entire procedure to prevent trauma to the urinary tract.
Tell the patient that he or she will have the desire to void as the cystoscope passes the bladder neck and with bladder distention.
• When the procedure is completed, bed rest should be prescribed for a short time if biopsies were performed.
• Note that this procedure is performed by a urologist in approximately 25 minutes.
After
Instruct the patient not to walk or stand alone immediately after the legs have been removed from the stirrups. The orthostasis that may result from standing erect may cause dizziness and fainting.
• Assess the patient's ability to void for at least 24 hours after the procedure if the patient is hospitalized. Urinary retention may be secondary to edema caused by instrumentation.
• Note the urine color. Pink-tinged urine is common. The presence of bright-red blood or clots should be reported to the physician.
• Monitor the patient for complaints of back pain, bladder spasms, urinary frequency, and burning on urination. Warm sitz baths and mild analgesics may be ordered and given. Sometimes belladonna and opium (B&O) suppositories are given to relieve bladder spasms. Warm, moist heat to the lower abdomen may help to relieve pain and to promote muscle relaxation.
• The first few times the patient voids after cystoscopy, burning will be felt in the urethra. This may be intense. Encourage men to urinate while sitting to avoid a vagal reaction related to severe dysuria.
Encourage increased intake of fluids. A dilute urine decreases dysuria. Fluids also maintain a constant flow of urine to prevent stasis and the accumulation of bacteria in the bladder.
• Monitor and record the patient's vital signs. Watch for a decrease in blood pressure and an increase in pulse rate as an indication of hemorrhage.
• Observe for signs and symptoms of sepsis (elevated temperature, flushing, chills, decreased blood pressure, increased pulse rate).
• Note that antibiotics are occasionally ordered 1 day before and continuing through 3 days following the procedure to reduce the incidence of bacteremia that may occur with instrumentation of the urethra and bladder.
Encourage the patient to use cathartics, especially after cystoscopic surgery. Increases in intraabdominal pressure caused by constipation may initiate urologic bleeding.
• If postprocedure irrigation is ordered, use an isotonic solution containing mannitol, glycine, or sorbitol to prevent fluid overhydration in the event any of the irrigation is absorbed through opened venous sinuses in the bladder.
• If a catheter is left in after the procedure, provide catheter care instructions.
Home Care Responsibilities
• Watch for signs of urinary retention for 24 to 48 hours.
• Watch for signs of bleeding. Pink urine is normal; clots are not.
• Report symptoms of increasing lower abdominal pain immediately.
• Use warm sitz baths or B&O suppositories to reduce bladder spasms.
• Encourage the patient to drink large amounts of fluids.
• Watch for fever, shaking chills, or prolonged dysuria as possible signs of urinary tract infection.
• Stress the importance of taking postprocedure antibiotics if ordered.
Test Results and Clinical Significance
Lower urologic tract tumor: Bladder cancers or polyps are seen as red friable tumors arising from the mucosa. Sometimes noninvasive tumors can be completely removed with the cystoscope.
Stones in the ureter or bladder: These can be retrieved through endourologic surgery. If the stones are too large for retrieval, they can be fractured mechanically or with laser or ultrasound.
Prostatic hypertrophy: This is a benign lesion that occludes the urethra. Removal of the portion of the prostate blocking the urethra (by TURP) resolves the obstruction.
Prostate cancer: This malignant lesion can obstruct the urethra. Removal of the portion of the prostate cancer that is blocking the urethra (by TURP) resolves the obstruction. In the elderly, this is not an aggressive tumor.
Inflammation of the bladder and urethra: A red thickened bladder mucosa indicates chronic infection. This may be because of urethral stricture, bladder diverticula, or inadequate bladder function.
Urethral, ureteral, or vesical stricture: A fibrous obstruction of the urethra or ureteral opening into the bladder indicates stricture, which is usually benign.
Ductoscopy (Mammary Ductoscopy)
Indications
Ductoscopy is used to visualize the breast ducts in women who have nipple discharge. Its accuracy and diagnostic potential depend on the experience of the surgeon and the patient's anatomy.
Test Explanation
Most breast cancers start in the cells that line the milk ducts within the breast ducts. Mammary ductoscopy refers to a procedure in which a “miniaturized endoscope” is used to get a closer look at the lining of milk ducts of the breast and provide access for biopsy or retrieval of cells lining the ducts.
The mammary ductoscopy consists of a tiny outer sheath with an external diameter only barely larger than a piece of thread. The sheath has two channels. In one channel, the camera light source is inserted. In the other channel, water is injected to dilate the ducts for better visibility. A video/endoscopic camera is attached and the images are projected on a TV monitor through a video system (Figure 4-9). The scope is then advanced to the smallest branches of the milk ducts.
With the use of this technique, breast diseases, including cancers, can be found at their very earliest stages. Ductoscopy can identify cancers so small that mammography, ultrasound, or even magnetic resonance imaging (MRI) cannot see them. With this technique, premalignant changes can be identified and treated in an attempt to prevent breast cancer. Mammary ductoscopy is used as a diagnostic technique in women with nipple discharge.
Ductal lavage (p. 645) is a technique used to obtain and identify premalignant atypical cells from breast ducts in patients who are considered high risk for cancer and who have no evidence of breast malignancy on mammogram or ultrasound. Ductoscopy is used to look into these ducts in the hopes of identifying the causes of those changes (e.g., intraductal papillomas or early cancers) in these ducts and possibly delivering ablative therapies to eradicate them.
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Be sure the breast exam and mammogram are normal.
• If the procedure is to be performed under general anesthesia, keep the patient on nothing by mouth (NPO) status for at least 8 hours.
• If the procedure is to be performed under local anesthesia, apply a topical anesthetic to the nipple area for about 30 to 60 minutes before the test.
During
• Note the following procedural steps:
1. The breast is massaged to promote the discharge of nipple fluid. This helps to visually identify the ductal orifice in the nipple for endoscopy.
2. The ductal opening in the nipple is gently dilated with increasing sized tiny dilators, and the mammary sheath containing the ductoscope is inserted and advanced under direct visualization as saline is injected to dilate the branches of the duct for visualization.
3. The ductoscopy findings can be recorded by videotape.
4. If any disease is identified, the scope can lead the surgeon directly to the area for directed surgical removal.
5. Ductal washings can also be obtained by aspiring some of the fluid for microscopic analysis.
• This procedure is usually performed by a surgeon in the office in approximately 30 minutes.
Test Results and Clinical Significance
Related Test
Breast Ductal Lavage (p. 645). With this procedure the breast ducts are flushed. Cells are obtained for cytology to identify malignant or premalignant cells.
Endoscopic Retrograde Cholangiopancreatography (ERCP, ERCP of the Biliary and Pancreatic Ducts)
Indications
This test is used in the evaluation of the jaundiced patient. It is also used to evaluate patients with unexplained upper abdominal pain or pancreatitis.
Test Explanation
With the use of a fiberoptic endoscope, ERCP provides radiographic visualization of the bile and pancreatic ducts. This is especially useful in patients with jaundice. If a partial or total obstruction of those ducts exists, characteristics of the obstructing lesion can be demonstrated. Stones, benign strictures, cysts, ampullary stenosis, anatomic variations, and malignant tumors can be identified. Only ERCP and percutaneous transhepatic cholangiography (PTHC) can provide direct radiographic visualization of the biliary and pancreatic ducts. PTHC (p. 1053) is an invasive procedure with significant morbidity; ERCP is associated with much less morbidity but must be performed by an experienced endoscopist.
Incision of the papillary muscle in the ampulla of Vater can be performed through the scope at the time of ERCP. This incision widens the distal common duct so that common bile duct gallstones can be removed. Stents can be placed through strictured bile ducts during ERCP, allowing the bile of jaundiced patients to be internally drained. Pieces of tissue and brushings of the common bile duct can be obtained by ERCP for pathologic review.
Manometric studies of the sphincter of Oddi and pancreatobiliary ducts can be performed at the time of ERCP. These are used to investigate unusual functional abnormalities of these structures.
Contraindications
• Patients who are uncooperative: Cannulation of the ampulla of Vater requires that the patient lie very still
• Patients whose ampulla of Vater is not accessible endoscopically because of previous upper gastrointestinal (GI) tract surgery (e.g., gastrectomy patients whose duodenum containing the ampulla is surgically separated from the stomach)
• Patients with esophageal diverticula: The scope can fall into a diverticulum and perforate its wall
• Patients with known acute pancreatitis, because ERCP can worsen this inflammation
Potential Complications
• Perforation of the esophagus, stomach, or duodenum
• Gram-negative sepsis: This results from introducing bacteria through the biliary system and into the blood. Usually this occurs in patients who have obstructive jaundice
• Pancreatitis: This results from pressure of the dye injection
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Obtain informed consent from the patient.
Inform the patient that breathing will not be compromised by the insertion of the endoscope.
Keep the patient on nothing by mouth (NPO) status as of midnight on the day of the test.
Tell the patient that no discomfort is associated with the dye injection but that minimal gagging may occur during the initial introduction of the scope into the oral pharynx.
• Administer appropriate premedication (e.g., midazolam [Versed] and atropine), if ordered.
During
• Note the following procedural steps:
1. A flat plate of the abdomen (see p. 1040) is taken to ensure that any barium from previous studies will not obscure visualization of the bile duct.
2. The patient is placed in the supine position or on the left side.
3. The patient is usually sedated with a narcotic and a sedative/hypnotic.
4. The pharynx is sprayed with a local anesthetic (lidocaine) to inactivate the gag reflex and to lessen the discomfort caused by the passage of the scope.
5. A side-viewing fiberoptic duodenoscope is inserted through the oral pharynx and passed through the esophagus and stomach and into the duodenum (Figure 4-10). A bite block may be used.
Figure 4-10 Endoscopic retrograde cholangiopancreatography (ERCP). The fiberoptic scope is passed into the duodenum. Note the small catheter being advanced into the biliary duct.
6. Glucagon is often administered intravenously to minimize the spasm of the duodenum and to improve visualization of the ampulla of Vater. Simethicone may be instilled to diminish any bubbles present that may inhibit visualization of the ampulla.
7. Through the accessory lumen within the scope, a small catheter is passed through the ampulla and into the common bile or pancreatic ducts.
8. Radiographic dye is injected, and x-ray images are taken.
• Note that the test usually takes approximately 1 hour and is performed by a physician trained in endoscopy. The x-ray images are interpreted by the radiologist.
After
Do not allow the patient to eat or drink until the gag reflex returns to prevent aspiration.
• Observe the patient closely for development of abdominal pain, nausea, and vomiting. This may herald the onset of ERCP-induced pancreatitis.
• Observe safety precautions until the effects of the sedatives have worn off.
• Monitor the patient for signs of respiratory depression. Medication (e.g., naloxone) should be available to counteract serious respiratory depression. Resuscitative equipment should also be present.
• Assess the patient for signs and symptoms of septicemia, which may indicate the onset of ERCP-induced cholangitis.
Inform the patient that he or she may be hoarse and have a sore throat for several days. Drinking cool fluids and gargling will help to relieve some of this soreness.
Home Care Responsibilities
• A sore throat is expected. A soothing mouthwash gargle may help.
• Notify the doctor immediately if increasing abdominal pain, nausea, or vomiting occurs. These may be the early signs of pancreatitis or gastroduodenal perforation.
• Notify the physician immediately of fever or shaking chills. These may indicate possible cholangitis.
• Encourage the patient to eat lightly for the next 12 to 24 hours.
Test Results and Clinical Significance
Tumor, strictures, or gallstones of the common bile duct: This is obvious in the presence and character of the filling defect noted in the dye-filled duct.
These are apparent as a long area of strictures involving, but not limited to, the extrahepatic ducts.
Cysts of the common bile duct: These congenital cysts are seen as large balloon-like dilations of any portion of the extrahepatic ducts.
Tumor, strictures, or inflammation of the pancreatic duct: Some tumors of the pancreas present as large cystic structures involving and leading from the pancreatic duct. Most pancreatic tumors, however, appear as a localized narrowing of the pancreatic duct with a dilated duct distal to the narrowing. Strictures and inflammation usually involve the entire duct with very little duct dilation beyond the narrowing.
Pseudocyst of the pancreatic duct: This results from pancreatic duct injury (usually following severe pancreatitis). The pancreatic juices leak out of the duct and into the peripancreatic tissue. A cyst is formed that communicates with the main pancreatic duct.
Chronic pancreatitis: This may be seen as multiple small partial strictures involving multiple short segments of the pancreatic duct with dilation of the duct in between the strictures. This gives the appearance of “beading” along the duct.
Anatomic biliary or pancreatic duct variations: Variable pathologic and nonpathologic anomalies can occur. Usually no symptoms are caused by these abnormalities.
Cancer of the duodenum or ampulla: These cancers are quite obvious as friable tumor masses emanating from the mucosa of those regions.
Related Test
Percutaneous Transhepatic Cholangiography (p. 1053). The liver is percutaneously punctured with a needle, and a catheter is threaded into the biliary duct radical. Dye is injected, and the biliary tree can be visualized radiographically.
Esophagogastroduodenoscopy (EGD, Upper Gastrointestinal [UGI] Endoscopy, Gastroscopy)
Indications
This test is used to visualize the lumen of the esophagus, stomach, and duodenum. It is used to evaluate patients with the following:
Test Explanation
Endoscopy enables direct visualization of the upper GI tract by means of a long, flexible, fiberoptic-lighted scope. The lumen of the esophagus, stomach, and duodenum are examined for tumors, varices, mucosal inflammations, hiatal hernias, polyps, ulcers, and obstructions. The endoscope has one to three channels. The first channel is used for viewing, the second for insufflation of air and aspiration of fluid, and the third for passing cable-activated instruments to perform a biopsy of suspected pathologic tissue. Probes also can be passed through the third channel to allow coagulation or injection of sclerosing agents to areas of active GI bleeding. A laser beam can pass through the endoscope to perform endoscopic surgery (e.g., obliteration of tumors or polyps, control of bleeding), and the fiberoptics of endoscopy are so refined that video images and “still pictures” can be taken.
With endoscopy, one can not only evaluate the esophagus, stomach, and duodenum, but with the use of an extra-long fiberoptic endoscope, one can also visualize and perform a biopsy of tissue in the upper small intestinal tract. This procedure is referred to as enteroscopy (Table 4-5). Abnormalities of the small intestine, such as arteriovenous (AV) malformations, tumors, enteropathies (e.g., celiac disease), and ulcerations, can be diagnosed with enteroscopy.
TABLE 4-5
Gastrointestinal Tract Endoscopy
| Endoscopy | Area Evaluated |
| Esophagoscopy | Esophagus |
| Gastroscopy | Esophagus and stomach |
| Esophagogastroduodenoscopy (EGD) | Esophagus, stomach, and duodenum |
| Enteroscopy | Esophagus, stomach, duodenum, and upper jejunum |
| Panendoscopy | Esophagus, stomach, duodenum, upper jejunum and colon (per colonoscopy) |
| Endoscopic retrograde cholangiopancreatography (ERCP) | Duodenum, ampulla, and pancreatobiliary ducts |
Until recently, there was no good way to directly visualize the mid and distal small bowel. Capsule endoscopy (or wireless capsule endoscopy) uses a capsule containing a miniature camera that records images of the entire digestive tract, particularly the small intestine. This capsule is about the size of a large vitamin and contains a color video camera, a radiofrequency transmitter, four LED lights, and enough battery power to take 50,000 color images during an 8-hour journey through the digestive tract. It moves through the digestive track naturally with the aid of peristaltic activity. During the 6- to 10-hour examination, the images are continuously transmitted to special antenna pads placed on the body and captured on a recording device about the size of a portable radio that is worn around the patient's waist. After the examination, the patient returns to the doctor's office and the recording device is removed. The stored images are transferred to a computer workstation, where they are transformed into a digital movie that the doctor can later examine on the computer monitor.
Patients are not required to retrieve and return the video capsule to the physician. It is disposable and expelled normally and effortlessly with the next bowel movement. The most common reason for doing capsule endoscopy is to search for a cause of bleeding from the small intestine. It may also be useful for detecting polyps, inflammatory bowel disease (Crohn disease), ulcers, and tumors of the small intestine. Capsule endoscopy is not accurate for the detection of colon neoplasia.
Besides being much more sensitive and specific than an upper GI x-ray series in diagnosing diseases of the esophagus, stomach, and duodenum, EGD also can be used therapeutically. An experienced endoscopist often can control active GI tract bleeding by electrocoagulation, laser coagulation, or the injection of sclerosing agents, such as alcohol. Also, with the endoscope, benign and malignant strictures can be dilated to reestablish patency of the upper GI tract. Biliary stents and a percutaneous gastrostomy tube can be placed with the use of EGD. The role of endoscopic surgery is expanding in light of its dramatic success and minimal morbidity.
Contraindications
• Patients who cannot cooperate fully: As in all studies that require technical finesse, patient cooperation is essential for successful, safe, and accurate test completion.
• Patients with severe upper GI tract bleeding: The viewing lens will become covered with blood clots, preventing adequate visualization. However, if the stomach can be lavaged and aspirated to clear the blood clots, EGD can be performed.
• Patients with esophageal diverticula: The scope can easily fall into the diverticulum and perforate the wall of the esophagus.
• Patients with suspected perforation: The perforation can be worsened by the insufflation of pressurized air into the GI tract.
• Patients who have had recent upper GI tract surgery: The anastomosis may not be able to withstand the pressure of the required air insufflation. This may lead to anastomotic disruption.
Potential Complications
• Perforation of the esophagus, stomach, and duodenum
• Pulmonary aspiration of gastric contents
• Oversedation from the medication administered during the test
• Hypotension induced by the sedative medication: Usually the patient already has some significant element of hypovolemia or dehydration.
• Local intravenous (IV) phlebitic reaction to the injection of sclerosing sedative medication
Procedure and Patient Care
Before
Explain the procedure to the patient.
Instruct the patient to abstain from eating as of midnight the day of the test.
Inform the patient that this test is mildly uncomfortable. Tell the patient that the throat will be anesthetized with a spray to depress the gag reflex.
Encourage the patient to verbalize concerns. Provide support.
Inform the patient that dentures and eyewear will need to be removed before the procedure starts.
Remind the patient that he or she will not be able to speak during the test but that respiration will not be affected.
Instruct the patient not to bite down on the endoscope.
Instruct the patient to perform thorough oral hygiene because the tube will be passed through the mouth.
During
• Note the following procedural steps:
1. The patient is placed on the endoscopy table in the left lateral decubitus position.
2. The throat is topically anesthetized with viscous lidocaine or another anesthetic spray. This is to decrease the gag reflex caused by passage of the endoscope.
3. The patient is usually sedated. This minimizes anxiety and allows the patient to experience a “light” sleep.
4. The endoscope is gently passed through the mouth and finally into the esophagus; once in the esophagus, visualization can be performed. A bite block may be used.
5. Air is insufflated to distend the upper GI tract for adequate visualization.
6. The esophagus, stomach, and duodenum are evaluated.
7. During enteroscopy, the upper small bowel is visualized and a biopsy is performed if needed.
8. Biopsy or any endoscopic surgery is performed with direct visualization.
9. At the completion of direct inspection and surgery, the excess air and GI tract secretions are aspirated through the scope.
• Note that the test is performed in the endoscopy laboratory by a physician trained in GI endoscopy and takes approximately 20 to 30 minutes.
After
Inform the patient that he or she may have hoarseness or a sore throat after the test.
Withhold any fluids until the patient is completely alert and the swallowing reflex returns to normal, usually 2 to 4 hours.
• Observe the patient's vital signs. Evaluate the patient for bleeding, fever, abdominal pain, dyspnea, or dysphagia.
Inform the patient that he or she may experience some postendoscopic bloating, belching, and flatulence.
• Observe safety precautions until the effects of the sedatives have worn off.
Inform the patient that the sedation may cause some retrograde and antegrade amnesia for a few hours.
Test Results and Clinical Significance
Tumors (benign or malignant) of the esophagus, stomach, or duodenum: These appear as red, friable ulcers or masses in the mucosa of the respective organ. These tumors can obstruct, bleed, or perforate.
Esophageal diverticula: These are outpouchings of the esophagus at the level of the cricopharyngeal muscle or the diaphragm.
Hiatal hernia: A hiatal hernia exists when a portion of the stomach is above the diaphragm (seen as an extrinsic compression of the lower esophagus).
Esophagitis, gastritis, duodenitis: A reddened friable mucosa without ulcer or mass is classic for inflammation.
Gastroesophageal varices: Submucosal vessels that protrude into the lumen of the distal esophagus and stomach are called varices and indicate a reversal of portal blood flow because of hepatic cirrhosis.
Peptic ulcer: This benign, acid-induced ulcer usually occurs in the duodenum but may occur in the distal stomach. It is a small to moderate-sized ulcer seen in the mucosa of the organ.
Peptic stricture and subsequent scarring: Following healing of an ulcer or inflammation, scarring and stricture can form and partially obstruct the lumen of the organ involved (usually the esophagus).
Extrinsic compression by a cyst or tumor outside the upper GI tract: Tumors, cysts, or enlarged organs can compress the upper GI tract. This is noted by a convex narrowing involving the organ being evaluated.
Source of upper GI tract bleeding: Ulcers, tumors, varices, AV malformations, inflammation, and bleeding can be identified and often treated by EGD.
Fetoscopy
Indications
Fetoscopy is indicated for any woman who is at risk for delivery of a baby with a significant birth defect. It is used also to perform corrective surgery on the fetus when possible.
Test Explanation
Fetoscopy is an endoscopic procedure that allows direct visualization of the fetus via the insertion of a tiny, telescope-like instrument through the abdominal wall and into the uterine cavity (Figure 4-11). Direct visualization may lead to diagnosis of a severe malformation, such as a neural tube defect. During the procedure, fetal blood samples to detect congenital blood disorders (e.g., hemophilia, sickle cell anemia) can be drawn from a blood vessel in the umbilical cord for biochemical analysis. Fetal skin biopsies also can be done to detect primary skin disorders. Fetoscopic surgery (placement of central nervous system [CNS] shunts, etc.) is becoming more and more a reality.
Fetoscopy is performed at approximately 18 weeks' gestation. At this time the vessels of the placental surface are of adequate size and the fetal parts are readily identifiable. A therapeutic abortion would not be as hazardous at this time as it would be if it were done later in the pregnancy. An ultrasound examination is usually performed the day after the procedure to confirm the adequacy of the amniotic fluid and fetal viability.
Potential Complications
Clinical Priorities
• Ultrasound examination is performed before the procedure to identify a safe area to enter the uterine cavity.
• After the test, mothers who are Rh negative should receive RhoGAM unless the fetal blood is also Rh negative.
• Ultrasound examination is usually performed the day after the procedure to confirm the adequacy of the amniotic fluid and to assess fetal viability.
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Obtain informed consent for this procedure.
• Assess the fetal heart rate (FHR) before the test to serve as a baseline value.
• Administer fentanyl, if ordered, before the test because it crosses the placenta and quiets the fetus. This prevents excessive fetal movement, which would make the procedure more difficult.
Tell the patient that the only discomfort associated with this study is the injection of the local anesthetic.
During
• Note the following procedural steps:
1. The woman is placed in the supine position on an examining table.
2. The abdominal wall is anesthetized locally.
3. Ultrasonography is performed to locate the fetus and the placenta and to identify a safe area to penetrate the uterus.
• Note that this procedure is performed by a physician in 1 to 2 hours.
After
• Assess the FHR and compare with the baseline value to detect any side effects related to the procedure.
• Monitor the mother and fetus carefully for alterations in blood pressure, pulse rate, uterine activity, and fetal activity; vaginal bleeding; and loss of amniotic fluid.
• Administer RhoGAM to mothers who are Rh negative unless the fetal blood is found to be Rh negative.
• If ordered, administer antibiotics prophylactically after the test to prevent amnionitis.
Test Results and Clinical Significance
Developmental defects (e.g., neural tube defects): These defects are visible on a fetus exceeding 20 weeks in age.
Congenital blood disorders (e.g., hemophilia, sickle cell anemia): These congenital abnormalities are identified by evaluation of the fetal blood.
Primary skin disorders: These may be obvious at the time of fetoscopy. Skin biopsies can be performed.
Related Tests
Amniocentesis (p. 632). This procedure involves placing a needle through the abdominal and uterine walls into the amniotic cavity to withdraw fluid for analysis. Valuable information about fetal status is obtained.
Chorionic Villus Sampling (p. 1088). This is a test whereby the chorionic placental tissue (which has the same genetic material as the fetus) is tested for genetic analysis and karyotyping. This is a rapid and accurate method of determining genetic defects. CVS can be performed earlier in pregnancy than can amniocentesis.
Hysteroscopy
Indications
This test allows direct visualization of the endometrial cavity. It is indicated for women with an abnormal Papanicolaou (Pap) test, dysfunctional uterine bleeding, or postmenopausal bleeding.
Test Explanation
Hysteroscopy is an endoscopic procedure that provides direct visualization of the uterine cavity by inserting a hysteroscope (a thin, telescope-like instrument) through the vagina and cervix and into the uterus (Figure 4-12). Hysteroscopy can be used to identify the cause of abnormal uterine bleeding, infertility, and repeated miscarriages. It is also used to evaluate and diagnose uterine adhesions (Asherman syndrome), polyps, and fibroids and to detect displaced intrauterine devices (IUDs).
In addition to diagnosing and evaluating uterine problems, hysteroscopy can also correct uterine problems. For example, uterine adhesions and small fibroids can be removed through the hysteroscope, thus avoiding open abdominal surgery. Hysteroscopy can also be used to perform endometrial ablation, which destroys the uterine lining to treat some cases of heavy uterine bleeding.
Hysteroscopy may confirm the results of other tests, such as hysterosalpingography (p. 1038). Depending on the amount of surgery and time associated with hysteroscopy, general, spinal, or light sedative anesthesia is used. It takes only about 30 minutes for simple hysteroscopy. This test is usually performed by a gynecologist in the operating room. The patient receiving local anesthesia or only light sedation may feel some cramping during the procedure. In general, it is not a painful procedure.
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Obtain informed consent for this procedure.
• Schedule the procedure after menstrual bleeding has ceased and before ovulation. This allows better visualization of the inside of the uterus and avoids damage to a newly formed pregnancy.
Inform the patient that hysteroscopy may be performed with local, regional, or general anesthesia. If general anesthesia will be given, the patient should be on nothing by mouth (NPO) status for at least 8 hours before the test. This test may also be performed without anesthesia.
Tell the patient to void before the procedure because a distended bladder can be more easily perforated.
During
• Note the following procedural steps:
1. Hysteroscopy may be performed in the operating room or in the doctor's office. Local, regional, general, or no anesthesia may be used. (The type of anesthesia depends on other procedures that may be done at the same time.)
2. The patient is placed in the lithotomy position. The vaginal area is cleansed with an antiseptic solution.
3. The cervix may be dilated before this procedure.
4. The hysteroscope is inserted through the vagina and cervix and into the uterus.
5. A liquid or gas is released through the hysteroscope to expand the uterus for better visualization.
6. If minor surgery will be performed, small instruments will be inserted through the hysteroscope.
7. For more detailed or complicated procedures, a laparoscope may be used (p. 617) to concurrently view the outside of the uterus.
8. After the desired procedure is performed, the hysteroscope is removed.
After
Tell the patient that it is normal to have slight vaginal bleeding and cramps for a day or two after the procedure.
Inform the patient that signs of fever, severe abdominal pain, or heavy vaginal discharge or bleeding should be reported to her physician.
If the patient has any discomfort from the gas inserted during the hysteroscopy or laparoscopy, assure her that this usually lasts less than 24 hours.
Test Results and Clinical Significance
Endometrial cancer, polyps, or hyperplasia: Cancer appears as thickened endometrium in one or multiple portions of the uterus. Hyperplasia looks similar but is not as isolated and seems more diffuse. Polyps appear as pedunculated mucosal tissue protruding from the endometrium.
Uterine fibroids: Small fibroids are easily seen because they distort the endometrium.
Asherman syndrome: Intrauterine adhesions may be associated with previous uterine infections and can be lysed through hysteroscopy.
Septate uterus: This and other developmental abnormalities can be visualized by hysteroscopy.
Displaced IUD: The location of a displaced IUD is easily seen.
Related Test
Dilation and Curettage (D&C) (p. 726). This is another procedure that allows one to examine scrapings of the endometrium under a microscope. This test has nearly the same indications as hysteroscopy. However, sampling is random, and serious lesions may be missed.
Laparoscopy (Pelvic Endoscopy, Gynecologic Video Laparoscopy, Peritoneoscopy)
Indications
Laparoscopy is used to directly visualize the abdominal and pelvic organs when a pathologic condition is suspected. It is used to evaluate patients with the following:
• Acute abdominal or pelvic pain
• Chronic abdominal or pelvic pain
Operative procedures that can be performed with laparoscopic surgery include oophorectomy, appendectomy, cholecystectomy, colectomy, hernia repair, liver biopsy, nephrectomy, tubal ligation, and gastrectomy.
Test Explanation
During laparoscopy the abdominal organs can be visualized by inserting a scope through the abdominal wall and into the peritoneum (Figure 4-13). An attached camera is applied to the scope, and the scope's view is seen on color monitors. This is particularly helpful in diagnosing abdominal and pelvic adhesions, tumors and cysts affecting any abdominal organ, and tubal and uterine causes of infertility. In addition, endometriosis, ectopic pregnancy, ruptured ovarian cyst, and salpingitis can be detected during an evaluation for pelvic pain. This procedure is also used to stage cancers and determine their resectability. Surgical procedures, as described above, can be performed with the laparoscope. As noted in Table 4-6, laparoscopy affords many advantages to the patient in comparison with an open laparotomy.
TABLE 4-6
Differences Between Laparotomy and Laparoscopy
| Laparotomy | Laparoscopy | |
| Difficulty in technique | Moderate | High |
| Size of incision | One large | Multiple and small |
| Expense of equipment in the operating room | Moderate | High |
| Expense of postoperative care | High | Low |
| Postoperative mobility | Low | High |
| Postoperative pain | High | Minimal to moderate |
| Postoperative hospitalization | 4-10 days | 1-2 days |
| Duration of postoperative recovery | Weeks | Days |
| Return to work | 6 weeks | 1 week |
Laparoscopy is performed by a surgeon. The patient is under general anesthesia so that no pain or discomfort is experienced during the procedure. Most patients have mild to moderate incisional pain. However, the patient may complain of shoulder or subcostal discomfort from diaphragmatic irritation caused by pneumoperitoneum.
Contraindications
• Patients who have had multiple abdominal surgical procedures, because adhesions may have formed between the viscera and the abdominal wall, making safe access to the abdomen impossible: There are techniques that allow limited laparoscopy in these situations.
• Patients with suspected intraabdominal hemorrhage, because visualization through the scope will be obscured by the blood
Interfering Factors
Clinical Priorities
• During the procedure the peritoneal cavity is filled with 3 to 4 L of CO2 to separate the abdominal wall from the intraabdominal viscera.
• After the procedure, patients may have shoulder or subcostal discomfort from pneumoperitoneum. This usually lasts only 24 hours.
• After the procedure, patients should be assessed for bleeding (increased pulse rate, decreased blood pressure) and perforated viscus (abdominal tenderness, guarding, decreased bowel sounds).
Procedure and Patient Care
Before
Explain the procedure to the patient.
Ensure that an informed consent for this procedure is obtained. Because of the possibility of intraabdominal injury, an open laparotomy may be required. Be sure the patient is aware of that.
If enemas are ordered to clear the bowel, assist the patient as needed and record the results.
• Because the procedure is usually performed with the patient under general anesthesia, follow the routine general anesthesia precautions.
• Shave and prepare the patient's abdomen as ordered.
Keep the patient on nothing by mouth (NPO) status after midnight on the day of the test. Intravenous (IV) fluids may be given.
Instruct the patient to void before going to the operating room because a distended bladder can be easily penetrated.
During
• After general anesthesia is induced, a catheter and nasogastric tube are inserted to minimize the risk of penetrating a distended stomach or bladder with the initial needle placement.
• Note the following procedural steps:
1. Laparoscopy is performed in the operating room. The patient is initially placed in supine position. Other positions may be assumed to maximize visibility.
2. After the abdominal skin is cleansed, a blunt-tipped (Verres) needle is inserted through a small incision in the periumbilical area and into the peritoneal cavity. Alternatively, a slightly larger incision is placed in the skin and the abdominal wall is separated under direct vision. The peritoneal cavity is entered directly. Adhesions can be lysed under direct vision.
3. The peritoneal cavity is filled with approximately 2 to 3 L of CO2 to separate the abdominal wall from the intraabdominal viscera, enhancing visualization of pelvic and abdominal structures.
4. A laparoscope is inserted through a trocar to examine the abdomen (see Figure 4-13). Other trocars can be placed as conduits for other instrumentation.
5. After the desired procedure is completed, the laparoscope is removed and the CO2 is allowed to escape.
6. The incision(s) is closed with a few skin stitches and covered with an adhesive bandage.
After
• Assess the patient frequently for signs of bleeding (increased pulse rate, decreased blood pressure) and perforated viscus (abdominal tenderness, guarding, decreased bowel sounds). Report any significant findings to the physician.
If patients have shoulder or subcostal discomfort from pneumoperitoneum, assure them that this usually lasts only 24 hours. Minor analgesics usually relieve this discomfort.
• If a surgical procedure has been performed laparoscopically, provide appropriate specific postsurgical care.
Home Care Responsibilities
• Observe for increasing abdominal pain, which may indicate bowel perforation.
• Note that fever and chills may indicate a bowel perforation.
• Inform the patient that discomfort in the shoulder area or under the ribs may result from the carbon dioxide inserted into the peritoneal cavity during the procedure.
Test Results and Clinical Significance
Abdominal adhesions: Occasionally these can be the source of chronic abdominal pain.
Ovarian tumor or cyst: These are obvious as masses affecting the ovaries.
Endometriosis: Endometriosis varies from small white wispy scars on the peritoneal surface to large inflammatory masses distorting normal anatomy.
Ectopic pregnancy: This usually appears to be a large mass with or without a surrounding inflammation involving just one fallopian tube.
Pelvic inflammatory disease (salpingitis): The pelvic structures are red and inflamed.
Uterine fibroids: Large soft masses are seen on and in the uterus.
Abscess or infection: This can come from any number of abdominal or pelvic causes, including appendicitis, infection of fallopian tubes, diverticulitis, or acute cholecystitis.
Cancer: A large primary or metastatic cancer in the abdomen is usually obvious. The extent of tumor spread can be assessed.
Ascites: Fluid within the abdomen can be aspirated and tested to indicate its source if not apparent at laparoscopy.
Other abdominal pathologic conditions: Every abdominal abnormality cannot be mentioned here. Suffice it to say that nearly every significant abdominal pathologic process that affects the visceral or parietal peritoneal surface can usually be seen.
Mediastinoscopy
Indications
This procedure provides direct visualization of the mediastinum and the lymph nodes contained within. It is used most commonly to determine the cancer stage of a person with known lung cancer. It is also used to evaluate patients with mediastinal masses of uncertain causes.
Test Explanation
Mediastinoscopy is a surgical procedure in which a rigid mediastinoscope (a lighted instrument scope) is inserted through a small incision made at the suprasternal notch. The scope is passed into the superior mediastinum to inspect the mediastinal lymph nodes and to remove biopsy specimens. Because these lymph nodes receive lymphatic drainage from the lungs, assessment of them can provide information on intrathoracic diseases such as carcinoma, granulomatous infections, and sarcoidosis; therefore mediastinoscopy is used in establishing the diagnosis of various intrathoracic diseases. This procedure is also employed to “stage” patients with lung cancer and to assess whether they are candidates for surgery. Evidence of metastasis to the mediastinal lymph nodes is usually a contraindication to thoracotomy because the tumor is considered inoperable. Biopsies of tumors occurring in the mediastinum (e.g., thymoma or lymphoma) can also be performed through the mediastinoscope.
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Ensure that the physician has obtained an informed consent for this procedure.
• Check whether the patient's blood needs to be typed and crossmatched.
• Provide preoperative care as with any other surgical procedure.
Keep the patient on nothing by mouth (NPO) status after midnight on the day of the test.
Inform the patient that he or she will be asleep during the procedure.
• Administer preprocedural medication approximately 1 hour before the test, as ordered.
During
• Note the following procedural steps:
1. The patient is taken to the operating room for this surgical procedure.
2. The patient is placed under general anesthesia.
3. An incision is made in the suprasternal notch.
4. The mediastinoscope is passed through this neck incision and into the superior mediastinum.
5. Biopsies of the lymph nodes are performed.
6. The scope is withdrawn, and the incision is sutured closed.
• Note that this procedure is performed by a surgeon in approximately 1 hour.
After
Home Care Responsibilities
• Assess for cough or shortness of breath, which may indicate a pneumothorax.
• Note that subcutaneous emphysema may indicate a pneumothorax.
• Assess for mediastinal crepitus on auscultation, which may indicate mediastinal air from a pneumothorax or the bronchus or esophagus.
• Note that distended neck veins and pulsus paradoxus (abnormal decrease in systolic blood pressure and pulse wave amplitude during inspiration) may indicate lack of cardiac filling because of a large mediastinal hematoma.
• Observe for hypotension and tachycardia, which may indicate bleeding from the biopsy site or the great vessels.
• Evaluate for hoarseness, which may indicate injury to the recurrent laryngeal nerve.
• Assess for fever, chills, and sepsis, which may indicate mediastinitis from infection.
Test Results and Clinical Significance
Lung cancer—primary into the mediastinum or metastatic to the lymph nodes: It is routine to stage lung cancers with mediastinoscopy prior to thoracotomy.
Thymoma: These tumors of the anterior superior mediastinum can be easily seen by this technique.
Tuberculosis or sarcoidosis: Granulomatous inflammations can involve the mediastinal lymph nodes.
Lymphoma or Hodgkin disease: Lymphomas routinely involve the mediastinum. In a patient with previously established lymphoma, this procedure is not needed. However, mediastinoscopy may be the least invasive method of diagnosis if lymphoma has not yet been diagnosed.
Infection (fungal, mycoplasma, etc.): Coccidioidomycosis, histoplasmosis, and Pneumocystis jiroveci can be diagnosed by this technique if the mediastinum is involved.
Related Test
Computed Tomography (CT) of the Chest (p. 1029). This test can visualize the mediastinal structure but cannot be specific about a disease process.
Sigmoidoscopy (Proctoscopy, Anoscopy)
Indications
This test allows for direct visualization of the rectum and sigmoid colon. It is used to diagnose suspected pathologic conditions of these organs. It is recommended for patients who have had a change in bowel habits or obvious or occult blood in the stool or who have abdominal pain. It is part of routine screening for colorectal cancer in people over age 50 years.
Test Explanation
Endoscopy of the lower gastrointestinal (GI) tract allows one to visualize and perform biopsies of tumors, polyps, hemorrhoids, or ulcers of the anus, rectum, and sigmoid colon. Anoscopy refers to examination of the anus; proctoscopy to examination of the anus and rectum; and sigmoidoscopy (the most frequent procedure) to examination of the anus, rectum, and sigmoid colon. This test can be performed with a rigid (to 25 cm from the anus) or flexible (to 60 cm from the anus) sigmoidoscope. Because the lower GI tract is difficult to visualize radiographically, direct visualization by sigmoidoscopy is diagnostically helpful.
Furthermore, sigmoidoscopy, like colonoscopy, can be therapeutic. Reduction of sigmoid volvulus, removal of polyps, and obliteration of hemorrhoids can be performed through the sigmoidoscope. For those having no colorectal cancer risk, the American Cancer Society recommends a sigmoidoscopy every 3 to 5 years after age 50 years. If a neoplastic abnormality (benign or malignant) is found, a total colonoscopy (p. 591) should be performed.
Note that a physician trained in GI endoscopy usually performs this procedure in the GI laboratory, operating room, or outpatient clinic or at the patient's bedside in approximately 15 to 20 minutes. Very little discomfort is associated with the test. A sense of having to defecate during the procedure is uncomfortable. It is caused by the scope within the rectum.
Contraindications
• Patients who are uncooperative
• Patients with diverticulitis: The insufflation of air needed to distend the rectum and colon for passage of the scope may cause a perforation of the diverticulitis.
• Patients with painful anorectal conditions (e.g., fissures, fistulas, hemorrhoids), because of the anal pain associated with passage of the scope
• Patients with severe bleeding: Blood clots obstruct the view of the scope.
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Obtain informed consent for this procedure.
Assist the patient with the bowel preparation. In most cases, two Fleet enemas are sufficient for examining the lower sigmoid colon and rectum. An oral cathartic is usually required to examine as far as 60 cm.
Instruct the patient to ingest only a light breakfast on the morning of the endoscopy.
Assure patients that they will be properly draped to avoid unnecessary embarrassment.
During
• Note the following procedural steps:
1. The patient is placed on the endoscopy table or bed in the left lateral decubitus position. Some physicians prefer the knee-chest position; many operating and examining tables are easily converted to make the knee-chest position more comfortable. This procedure also can be performed with the patient in the lithotomy position.
2. Usually no sedation is required.
3. The anus is mildly dilated with a well-lubricated finger.
4. The rigid or flexible sigmoidoscope is placed into the rectum and advanced to its point of maximal penetration.
5. Air is insufflated during the procedure to more fully distend the lower intestinal tract.
6. The sigmoid, rectum, and anus are visualized.
7. Biopsy specimens can be obtained and polypectomy can be performed at the time of sigmoidoscopy.
After
Inform the patient that because air has been insufflated into the bowel during the procedure, he or she may have flatulence or gas pains. Ambulation may help.
• Observe the patient for signs of abdominal distention, increased tenderness, or rectal bleeding.
Tell the patient that slight rectal bleeding may occur if biopsy specimens have been taken.
Home Care Responsibilities
• Observe for increasing abdominal pain, which may indicate bowel perforation.
• Note that fever and chills may indicate a bowel perforation.
• Inform the patient that frequent bloody bowel movements may indicate poor hemostasis if biopsy or polypectomy was performed.
• Observe for abdominal bloating and inability to pass flatus, which may indicate colon obstruction if a neoplasm was identified.
Test Results and Clinical Significance
Colorectal cancer: This is seen as a red friable fleshy tumor concentrically involving the mucosa of the bowel.
Colorectal polyp: This is a tumor that protrudes from only one part of the mucosa of the bowel. Some cancers and most polyps can be removed with the sigmoidoscope. Biopsy specimens can be obtained from neoplasms.
Ulcerative proctitis: Ulcerative colitis frequently involves the rectum. That is one characteristic that separates ulcerative colitis from Crohn disease.
Pseudomembranous colitis: The rectum is the best location to most easily make the diagnosis of this disease. Usually this inflammation is the result of Clostridium overgrowth caused by prolonged use of clindamycin.
Intestinal ischemia: This usually is apparent as dark mucosa in the sigmoid colon. The sigmoid colon is the portion of colon most vulnerable if ischemia occurs. Ischemia always shows up in the mucosa first.
Related Tests
Barium Enema (p. 994). This is an x-ray contrast study of the colon and rectum. The rectum, however, is not well evaluated by this study.
Colonoscopy (p. 591). This is a direct visualization of the entire colon and rectum. It is more extensive and invasive than sigmoidoscopy. The required preparation is more complete.
Sinus Endoscopy
Indications
This procedure is used to evaluate and treat patients with recurrent or resistant sinus infections.
Test Explanation
Patients with recurrent or resistant sinus infections often require surgical drainage. However, with the advent of sinus endoscopy (Figure 4-14), the sinus cavities can be accessed and drained without surgery. Cultures can be obtained, and antibiotic therapy can be more appropriately provided. The treatment of sinusitis is important to prevent the development of complications, such as mucoceles, cysts, or sinus bone destruction. The most accessible sinuses include the anterior ethmoid, middle turbinate, and middle meatus areas.
This procedure can also be used to visualize suspected neoplasms involving the sinuses. The test is usually performed by a surgeon trained in ear, nose, and throat (ENT) diseases. There is usually little postoperative pain associated with this procedure.
Procedure and Patient Care
Before
Explain the procedure to the patient.
• Ensure that an informed consent for this procedure is obtained.
If the procedure is to be performed under general anesthesia, keep the patient on nothing by mouth (NPO) status after midnight on the day of the test. Intravenous (IV) fluids may be given. This procedure can also be done using local anesthesia, depending on the amount of endoscopic surgery that will be required.
During
• Note the following procedural steps:
1. Sinus endoscopy is performed in the operating room if general anesthesia is required; otherwise it can be done in the office. The patient is initially placed in the supine position.
2. After the skin near the nose and mouth is cleansed, the nose is sprayed with a Xylocaine/epinephrine solution to diminish any bleeding.
3. The sinuses are viewed with an endoscope preformed at various angles to permit optimal viewing.
4. Sinus contents are examined and aspirated for culture testing.
After
• Place a 4 × 4 gauze pad under the nose to collect any fluid or blood that may further drain from the nose.
• If a cerebral spinal fluid leak is suspected, the fluid can be checked for sugar with a Dextrostix. Spinal fluid contains glucose.
• Assess the patient frequently for signs of bleeding. Report any significant findings to the physician.
Thoracoscopy
Indications
This procedure is used to directly visualize the pleura, lung, and mediastinum. Tissue can be obtained for testing. It is also helpful in assisting in the staging and dissection of lung cancers.
Test Explanation
Thoracoscopy is experiencing a renewal as a result of the development of instrumentation for operative laparoscopy. With this technique the parietal pleura, visceral pleura, and mediastinum can be directly visualized. Tumors involving the chest cavity can be staged by direct visualization. A biopsy of any abnormality can be performed. Collections of fluid can be drained and aspirated for testing. Dissection for lung resection can be carried out with the thoracoscope (video-assisted thoracotomy [VAT]), thereby minimizing the extent of a thoracotomy incision. VAT is especially helpful for lung biopsy in patients with pulmonary nodules of uncertain cause or for suspected Pneumocystis infections in immunocompromised patients.
The patient must be aware of the possibility of requiring an open thoracotomy if the procedure cannot be performed thoracoscopically or if bleeding occurs that cannot be controlled any other way. Any patient who can have an open thoracotomy can have a thoracoscopy.
Procedure and Patient Care
Before
Explain the procedure to the patient.
Ensure that an informed consent for this procedure is obtained. Because of the possibility of intrathoracic injury, an open thoracotomy may be required. Inform the patient of this possibility.
• Because the procedure is usually performed with the patient under general anesthesia, follow the routine general anesthesia precautions.
• Shave and prepare the patient's chest as ordered.
Keep the patient on nothing by mouth (NPO) status after midnight on the day of the test. Intravenous (IV) fluids may be given.
During
• Note the following procedural steps:
1. Thoracoscopy is performed in the operating room. The patient is initially placed in the lateral decubitus position.
2. After the thorax is cleansed, a blunt-tipped (Verres) needle is inserted through a small incision and the lung is collapsed.
3. A thoracoscope is inserted through a trocar to examine the chest cavity. Other trocars can be placed as conduits for other instrumentation.
4. After the desired procedure is completed, the scope and trocars are removed.
5. Usually a small chest tube is placed to ensure full reexpansion of the lung.
6. The incision(s) is closed with a few skin stitches and covered with an adhesive bandage.
After
• Assess the patient frequently for signs of bleeding (increased pulse rate, decreased blood pressure). Report any significant findings to the physician.
• Provide analgesics to relieve the minor to moderate pain that may be experienced.
• If a surgical procedure has been performed thoracoscopically, provide appropriate specific postsurgical care.
• Note that a chest x-ray examination is performed after the procedure to ensure complete reexpansion of the lung.
• If a chest tube is left in place, provide assessment and care.
Test Results and Clinical Significance
Metastatic cancer to the lung or pleura:
Often these tumors can be easily seen and biopsies performed, or the tumors can be removed through or with the help of thoracoscopy.
Empyema: The infected fluid can be drained directly and valuable specimens obtained for cultures.
Pleural diseases such as tumor, infection, or inflammation: Biopsies of either the parietal or visceral pleura can be performed during this procedure.
Pulmonary infection: Thoracoscopy is particularly helpful in obtaining lung tissue for suspected infections such as tuberculosis, Pneumocystis jiroveci, coccidioidomycosis, or histoplasmosis.
Related Test
Laparoscopy (p. 617). This test is to the abdomen as thoracoscopy is to the chest. Most of the instruments are the same.